RN Staffing in the NICU - Position Statement #3074

RN Staffing in the NICU

Position Statement

#3074

NANN Board of Directors

September 2021

Appropriate staffing is required to deliver safe and effective care to NICU

patients: vulnerable infants who are wholly dependent on their caregivers.

A sufficient number and appropriate mix of qualified registered nurses

(RNs) are needed in subspecialty NICUs (Levels II, III, and IV). However,

evidence suggests understaffing is a substantial problem, one that puts

patients at increased risk of missed or rationed care, medical incidents,

disparities of care, and morbidity and mortality. As the professional voice of

neonatal nurses, the National Association of Neonatal Nurses (NANN)

recommends staffing be based on the acuity of the population served and

that the principles of staffing and finance be shared with frontline nurses

who then have a say in the development of staffing policies.

Association Position

The delivery of safe and effective neonatal nursing care requires the assurance of a

sufficient number and an appropriate mix of qualified registered nurses (RNs) to attend

to the emergent and complex care requirements of critically ill and convalescent infants

in subspecialty NICUs (Levels II, III, and IV).

Background

The issue of staffing is not a new one. In Notes on Nursing, Florence Nightingale (1859)

observed that “bad sanitary, bad architectural, and bad administrative arrangements

often make it impossible to nurse” (p. 59). She went on to discuss what nursing is and is

not, describing elements of care that we consider essential to modern nursing care and

neonatal nursing care: attention to cleanliness, sanitation, warmth, and nutrition. More

than 160 years later, health care has become increasingly complex, and nursing care

remains the most essential component of that care.

Health care continues to evolve, and so do nursing services. The 2010 Patient

Protection and Affordable Care Act, commonly called the Affordable Care Act (ACA),

aims to provide comprehensive health care to citizens of the United States. With the

enactment of the ACA have come inevitable changes in the delivery of nursing services

as more citizens become eligible for affordable care. In 2011, the Institute of Medicine

(IOM)—now the National Academy of Medicine—published The Future of Nursing,

which addresses issues facing the profession, including staffing. There is evidence of a

direct link between nursing care and higher quality of care, including improved patient

safety.

According to the American Nurses Association (ANA), appropriate nurse staffing can be

characterized as “an ever-present challenge of managing the delicate balance of the

polarities of mission (improving population health and the quality and satisfaction for

patients, clinicians, and staff) and margin (operations and per capita cost of health

care)” (ANA, 2020, p. 5). Appropriate nurse staffing is defined as a match of registered

nurse expertise with the needs of the recipient of nursing care services in the context of

the practice setting and situation (ANA, 2020 p. 6).

In 2020, ANA revised its Principles for Nurse Staffing. The five principles are designed

to help nurses at all levels develop and implement appropriate staffing plans. They are

● Characteristics and considerations of the healthcare consumer or patient

● Characteristics and considerations of registered nurses and other

interprofessional team members and staff

● The context of the organization and workplace culture in which nursing

services are delivered

● The overall practice environment that influences the delivery of care

● Evaluation of staffing plans, overall costs, effectiveness, and resources

expended for nursing care (ANA, 2020, p. 65).

ANA also delineates seven core components of appropriate nurse staffing, including

● Registered nurses are full partners working with other healthcare professionals

in the collaborative, interprofessional delivery of safe, quality health care.

● All settings should have well-developed staffing guidelines with measurable

nurse-sensitive outcomes specific to that setting and healthcare consumer

population that are used as evidence to guide daily staffing.

● Registered nurses at all levels within a healthcare system must have a

substantive and active role in staffing decisions to assure the availability of the

necessary time with patients to meet care needs and overall nursing

responsibilities.

● Staffing needs must be determined based on an analysis of consumer

healthcare status (eg. degree of stability, intensity, and acuity) and the

environment in which the care is provided. Other considerations include

professional characteristics, competencies, experience, and skillset; staff mix;

and previous staffing patterns that have been shown to improve care outcomes.

● Appropriate nurse staffing should be based on allocating the appropriate

number of competent practitioners to a care situation, meeting consumer-

centered and organizational outcomes, pursuing quality of care indices, meeting

federal and state laws and regulations, and assuring a safe, high-quality work

environment.

● Cost-effectiveness is an important consideration in the delivery of safe, quality

care. Nurse leaders must evaluate and balance patient care needs and the

overall nursing care resources and costs expended for care.

● Reimbursement structures should not influence nurse staffing patterns or the

level of care provided (ANA, 2020, p. 6).

Significance

The significance of safe and appropriate staffing in the NICU cannot be understated.

The breadth of this population is substantial, ranging from the most immature, small,

and/or medically complex patients to infants who are growing and convalescing. What

differentiates the NICU population from most other populations is that 100% of the NICU

population is 100% dependent upon their caregivers for all care and activities of daily

life. There is evidence that understaffing relative to national guidelines is a substantial

problem. Rogowski et al. wrote in 2013 that “in 2009, 55% of units understaffed at least

25% of their infants and 16% understaffed at least 50% of their infants” (p. 447). This is

a substantial risk to the care of these very high-risk infants. The neonatal population is

also particularly vulnerable to events requiring emergency measures, including

metabolic disturbances, respiratory emergencies, and cardiovascular events. The need

for resuscitation can occur at any time during hospitalization, and adequate and

appropriate staffing is required for the necessary care to be provided.

Missed Care/Rationing Care

Nurses’ ability to deliver highly reliable care to their patients is critical for sustaining and

improving the quality of care. Missed care interferes with the ability to improve the care

that is delivered and, therefore, the outcome. Hart et al. (2019) define nursing workload

as the time that nurses devote to direct and indirect patient care, workplace activity as

well as professional development. Care that is either omitted or delayed is commonly

theorized to be an outcome of high nursing workload (Tubbs-Cooley et al., 2019). This

high nurse workload can be the result of more assigned patients, higher acuity scores of

the individual patients, or higher subjective ratings of workload. In the 2019 study

conducted by Tubbs-Cooley et al., missed care was reported at the end of a shift,

resulting in less than 1% missing data. Missed care was reported in 98.2% of the

nursing shifts. Nurses had patient loads as high as 1:4 (nurses:patients); the mean

nursing ratio was 1:2. In 24% of corresponding infant-nurse shifts (2,502 of 10,428

infant shifts), missed care was reported. Nurses most commonly reported missing

hourly checks of IV lines and adherence to CLABSI bundles. Interestingly, this study

measured subjective workload using the NASA Task Load Index (NASA-TLX) and

found that nursing ratios were not the only driver of missing care and that subjective

assessment of workload needs was a largely unmeasured and yet predictive aspect of

nursing care that led to missed care.

Medical Incidents

Within the context of a study evaluating overtime utilization, nursing provision, and unit

occupancy rate, Beltempo et al. (2018) evaluated medical incidents, mortality, or major

morbidity among very preterm infants born at less than 29 weeks gestational age or a

weight of less than 1000 grams. In this study, the rate of medical incidents was

assessed as an indicator of quality of care. Medical incidents were defined as

“observable errors in the process of care with or without direct consequences on the

patient’s health” (Beltempo et al., 2018, p. 176). They found medical incidents occurred

on days with lower median nursing provision ratios.

Disparity in Care

The National Academy of Medicine found that “bias, stereotyping, prejudice and clinical

uncertainty on the part of healthcare providers may contribute to racial and ethnic

disparities in healthcare” (Horbar et al., 2019, p. 459). In the United States, being Black

and having low socioeconomic status are major risk factors for preterm birth and are

often linked to inadequate access to prenatal care (Engelhardt et al., 2018). A

systematic review on racial and ethnic health disparities found that very low birth weight

(VLBW) infants born in high-black concentration hospitals have higher rates of infection,

discharge without breast milk, and nurse understaffing (Lake et al., 2015). These

structural barriers likely translate to higher risk-adjusted VLBW infant mortality and

morbidity rates (Sigurdson et al., 2018). Structural racism refers to policies, laws, and

regulations that systematically result in different access to opportunities based on race.

Structural racism paired with social determinants of health can result in healthcare

inequities (Johnson, 2020).

Infants born in hospitals with a high concentration of black babies experienced

significantly higher patient-to-nurse ratios and had worse outcomes (Sigurdson et al.,

2019; Lake et al., 2018). This is concerning as inadequate staffing leads to missed care

which can negatively impact outcomes. Nurses in NICUs with a high percentage of

black babies missed 50% more activities than in NICU’s with a low percentage of black

infants, which were a result of a higher patient-to-nurse ratio (Lake et al., 2018).

Having a global understanding of how healthcare systems operate, including the

dissimilar settings in which healthcare professionals and their patients live and work is

imperative in understanding how residential segregation impacts access to care and

quality of the health-care system and provider (Bailey et al., 2017). The patient-to-nurse

ratios and missed care in minority-serving hospitals were much higher than in other

hospitals, suggesting that improving staffing and workloads would improve quality of

care at minority-serving hospitals (Beck et al., 2020).

Morbidity and Mortality

Beltempo et al. (2018) found that in infants born at less than 29 weeks gestational age

or less than 1000 grams weight, the risk of developing the composite outcome of

mortality or major morbidity is lower for infants who had high nursing provision ratios.

This is true for the infants’ first day, first week, and entire NICU hospitalization. Because

critically ill infants are a high-risk and unique population for which nurses provide

continuous care, the consequences of errors or missed care can be substantial. In

addition, fragile neonates who are exposed to adverse events are more likely to

experience long-term morbidity (Hart et al., 2019).

Watson et al. (2016) studied the effect of one-on-one care in a tertiary-level NICU. This

study found an increased mortality rate in this NICU when a decreased proportion of

intensive care days was provided as one-on-one care. Utilizing their estimation of

decreased mortality rate, they estimated that the cost of providing this level of care per

life saved was the equivalent of $16,678 (in 2016 dollars). Hart et al. (2019) evaluated

insufficient staffing in the NICU and determined that it is associated with missed nursing

care. When important and necessary nursing care is missed in the NICU, adverse

events and poor patient outcomes are more likely. Neuraz et al. (2015) assessed the

impact of the patient-to-nurse ratio and workload on ICU mortality, noting that the risk of

death is increased significantly the higher the number of patients allocated to each

nurse. Lake et al. (2020) found that 49% of nurses missed at least one nursing care

activity with increased acuity load compared to only 27% with low acuity workload.

Missed nursing care is defined by the study as “required nursing care that is omitted or

delayed” (Lake et al., 2020, p. 451). The authors stated that “any missed nursing care

has the potential to compromise infant health outcomes in the hospital and in the future

as infants grow and develop” (Lake et al., 2020, p. 451).

Reducing the incidence of morbidity is possible and carries with it substantial benefit to

the infant, the family, and society as a whole. The likelihood of good long-term health

and neurodevelopment is greater than 90% if a VLBW infant is discharged to home

without any major morbidity (Kaempf et al., 2019). Major morbidities, as described

below, are sensitive to nurse staffing and represent a significant burden.

Infection

Neonatal sepsis is a preventable morbidity associated with increased mortality,

increased length of stay, and neurodevelopmental impairment. Appropriate nurse

staffing in the NICU is associated with decreased rates of central line-associated

bloodstream infections (Cimiotti et al., 2006).

Rogowski et al. (2013) measured understaffing in a variety of units relative to acuity-

based guidelines; their data suggested substantial NICU nurse understaffing relative to

national guidelines, an understaffing that is higher among high-acuity infants. In this

large data set, consisting of 67 hospitals and more than 10,000 infants over 2 years,

understaffing was associated with an increased risk of nosocomial infections. They

predicted that the infection rate in a unit with no understaffing was 9% compared to 14%

at aa unit at the median understaffing rate; at the 90th percentile of understaffing, the

predicted infection rate rose to 21% (Rogowski et al., 2013).

Hospitals have often used overtime to improve staffing during periods of insufficient

staffing. Beltempo et al. (2017) studied nursing staffing, overtime, and unit occupancy,

and these factors’ effects on hospital-acquired infections. They found increased odds of

infection following days of increased overtime utilization, even when controlling for unit

confounders. This is consistent with evidence from adult populations, where increased

use of overtime is associated with greater fatigue and lower task performance. Fatigue

is an important issue for nursing in all clinical areas and beyond the scope of this

statement.

ROP

Retinopathy of prematurity (ROP) is a vasoproliferative disorder that has been

associated with oxygen exposure in premature infants (Higgins, 2019). Efforts to reduce

ROP rates and severity have focused on tight oxygen targeting. Until recently, the

optimal oxygen saturation levels were not known. The Surfactant, Positive Pressure,

and Oxygenation Randomized Trial (SUPPORT trial) and Benefits of Oxygen Saturation

Targeting (BOOST II trial) resulted in findings of increased mortality when infants were

managed at the low oxygen target level. In the case of the BOOST trial, it resulted in

halting the study early. In a recent meta-analysis, the lower SpO

target range was

associated with a higher risk of death and necrotizing enterocolitis but a lower risk of

ROP treatment (Askie et al, 2018).

Episodes of oxygen desaturation are common in preterm infants and must be

responded to promptly to maintain appropriate oxygenation levels in these vulnerable

infants. Automated adjustment of oxygen is available only as an experimental device

(Waitz et al., 2015) that is unlikely to soon be available for general use. Thus, nurses

must be available to respond efficiently to out-of-range alarms. Response to out-of-

range events and the effect it has on ROP has been evaluated as part of quality

improvement studies. Gentle et al. (2020) evaluated the use of monitor histograms to

alert nursing staff to the duration of time infants spent out of range; the study

documented an increase in the amount of time spent in the target zone (48.7% to

57.6%) and a decrease in the rate of the outcome “death or severe ROP” (32.1% to

18%).

BPD

An association between staffing and the specific outcome of bronchopulmonary

dysplasia (BPD) has not been studied. However, in a study by Beltempo et al. (2018),

the composite outcome of death from all causes and major morbidity was associated

with lower nursing provision ratios. The authors state that “association of the nursing

provision with the composite outcome was mainly related to the bronchopulmonary

dysplasia rates, the two being inversely related” (Beltempo et al., 2018, p. 177 ). The

data support the need for a nurse’s workload to be aligned with each patient’s unique

needs; in this case, the nurse must be able to comply with meticulous respiratory or

BPD practice guidelines.

Oxygen targeting issues that affect ROP rates also affect BPD rates. Additionally, the

SUPPORT trial (2010) found that the use of noninvasive ventilation or continuous

positive airway pressure (CPAP) is associated with the reduction in rate of BPD. This

strategy requires increased nursing time because this population requires meticulous

monitoring of physiologic status to prevent undesirable outcomes such as

pneumothorax or nasal trauma (Roberts, 2011).

Feeding

One of three major tasks a premature or sick infant must accomplish to be discharged

from the NICU is feeding. Preterm infants at term equivalent age are more likely to have

feeding difficulties than term infants. They may experience

poor arousal, poor tongue positioning, suck–swallow–breathe discoordination,

inadequate sucking bursts, tonal abnormalities, discoordination of the jaw and

tongue during sucking, lack of positive engagement or discomfort, signs of

aspiration, difficulty regulating breathing, and inability to maintain an appropriate

state and complete the feeding (Pineda et al., 2020, p. 650).

Late-preterm infants, who may be physiologically stable, may require considerable

attention related to enteral feeding. Supporting breastfeeding throughout all infant

gestations also can be time intensive (McGrath et al., 2010).

A diet of maternal breast milk has been associated with a decreased risk of necrotizing

enterocolitis. In a study evaluating the use of quality improvement methods to reduce

NEC, Gephart and Quinn (2019) found that maternal lactation support is paramount to

the delivery of NEC prevention practices. Education, instruction, support, and

encouragement from skilled nursing staff are essential components to ensuring

breastfeeding success which protects the health of babies and their mothers.

In a study evaluating NICU work environments, Hallowell et al. (2016) found that NICUs

with better work environments, better educated nurses, and more infants who receive

breastfeeding support from nurses have higher rates of VLBW infants discharged home

on human milk. All of these factors contribute to feeding success in convalescent

infants in the NICU and require available staff to accomplish this important milestone for

discharge,

Acuity Scoring

Rogowski et al. (2015) identified the NICU as a setting with a high nurse-to-patient ratio

and determined that in this highly intensive setting, these staffing patterns may not

optimize patient outcomes. They found that infant acuity was the sole determinant of

nurse workload. The presence of other members of the care team was not associated

with nurse-to-infant ratios, and nurse education, experience, and specialty certification

were not reflected in nurse-to-infant ratios. Identifying the determinants of nurse staffing

based on acuity measurement was an important first step in understanding how

outcomes can be improved through adequate nurse staffing levels.

Al-Dweik and Ahmad (2019) stated that “linking nursing shift assignments to patients’

acuity scores may increase the workload balance, achieve equitable nursing

assignments, and nurses’ satisfaction” (p. E34). Their utilization of a patient acuity score

showed significant improvement in balanced work assignments, potentially improving

satisfaction in the areas of workload and standards of nursing care. By using a data-

driven acuity-based approach to staffing, nursing care performance can be measured at

the individual patient level to customize care while optimizing staffing practices (Welton,

2017).

Utilizing an evidence-based approach, NICU nurses must participate in all levels of

staffing within an organization in order to support the high acuity and low volume

fluctuations experienced. There is no standardized risk assessment tool or established

clinical indicators that allow for the clear identification of equitable assignment

distribution that ensures safe delivery of nursing care. Rather than utilizing traditional

nurse-to-patient ratio-based assignments, nurses have an extensive interest in

operationalizing a process to achieve staffing effectiveness and a healthy work

environment.

Proper technologies are needed to support, capture, and communicate patient

assignments and patient workload in order to balance economics and quality outcomes.

Addressing unique ICN patient needs and the varying needs of patients with different

acuity levels can be done by utilizing scoring as a vehicle to determine patient

requirements. Ingram and Powell (2018) stated assigning a level of care according to

patient needs addresses issues of unbalanced assignments and allows nurses to

influence decision-making as stakeholders while building a standard of care. Al-Dweik

and Ahmad’s 2019 evidence suggests acuity-based assignments affect patient safety,

productivity, patient outcomes, and quality of care—identifying communication, fair

distribution, and assignment transparency as key elements.

Nursing workload is an important aspect of NICU nursing that remains largely

unmeasured despite the potential for significant intervention (Tubbs-Cooley et al.,

2019).

Recommendations

It is clear that staffing rates matter. Data show that improvement in staffing improves

outcomes on multiple levels. This supports stronger staffing ratios. It also is clear that

minimal staffing ratios and optimal staffing ratios are different.

We believe that every infant under our community of care should have staffing based on

their physiological and psychosocial needs. We, as a community, must work to

eliminate inequities where they exist. Inequities in care delivery are unacceptable.

When minimum staffing ratios are set by states, they must be followed, but minimum

staffing ratios are just that: minimums. Exceeding minimum staffing ratios is allowable

and may be required.

NANN makes the following recommendations regarding appropriate RN staffing of

subspecialty NICUs (Levels II, III, and IV).

1. ANA’s Principles for Nurse Staffing (3rd Ed.) should inform decisions about RN

staffing in units where care is given to critically ill and convalescent newborns.

2. Staffing guidelines should be based upon the acuity of the population served.

There are few acuity tools developed for NICUs and their applicability from unit to

unit has not been established. Nonetheless, the principles of measuring and

accounting for acuity are applicable. We recommend each unit evaluate their

acuity in a standardized manner with the goal of evaluating nurse-centered

outcomes and care delivery, not resource utilization. The goals of any acuity

assessment are to allocate an appropriate number of staff to meet unit and

organizational goals, pursue quality indices, meet regulatory requirements, and

assure a safe, high-quality work environment. Skillset, staff mix, experience, and

competencies all play a role in staffing and should be considered when assessing

adequacy of any safe staffing plan. Family care, teaching, and support also must

be considered in acuity assessment.

3. Because populations and care trends change, we recommend periodic evaluation

of the effectiveness of the individual strategy or tool used for measuring acuity.

Additionally, we recommend evaluating the unit staffing adequacy to determine if

units are meeting staffing goals and patient needs on an ongoing basis. Evaluation

of staffing plans should include real-time capturing of missed care. When missed-

care events occur, they should be evaluated in sum as an opportunity to discern

patterns. When patterns are found, staffing plans should be adjusted or systems

should be created to mitigate the frequency of missed care.

4. Development of staffing policy should include formal input from frontline staff in

collaboration with nursing administration. The frontline staff’s role and proximity to

the patient and family provide a unique perspective that must be considered. This

should be a goal for all phases of staffing: planning, implementation, problem

solving, and evaluation of effectiveness. Staff participation in staffing-policy

development is an important expectation of appropriate staffing, one of six

components of a healthy work environment as defined by the American

Association of Critical Care Nurses (Blake, 2015).

5. Staff nurses at all levels involved in staffing decisions should learn about principles

of staffing and finance. Financial stewardship is a balance between judicious use

of resources and appropriate allocation of resources. Both frontline providers and

hospital administration have a responsibility in this regard. A financially exhausted

healthcare system serves no one’s needs. Increasingly, the concept of “value” is

cited in making decisions about resource utilization. Value has been defined as

“providing the optimal outcome per health dollar spent. Improving the value of

health care for patients and healthcare organizations requires an understanding

and evaluation of the costs and benefits” (Fischer & Duncan, 2020, p. 972). This

requires that facilities be transparent regarding factors influencing budgets for

staffing. We recommend that facilities utilize existing technologies to evaluate

drivers of acuity and support capture of staffing issues, missed care, and adverse

outcomes. The goal is to develop strategies to assist staff with these clinical

situations. In some instances, nurse extenders may augment but not replace

nurses if permitted by local regulations.

6. Census and acuity fluctuations occur; therefore, staffing needs must be tailored to

create an equitable and effective method of responding to these changes in order

to support a healthy work environment for staff while providing quality patient care.

A staff-driven initiative which addresses reserve capacity as well as established

and effective float guidelines for staffing will ensure a consistent practice

environment. Each unit must develop a process to identify, optimize, and utilize

staffing resources. These guidelines will provide a flexible staff floating policy and

an order of staff reduction as needed for low census. In units with low patient

volumes, a sufficient quantity of staff must be available to immediately respond to

emergencies. This means they must be immediately available although they can

have other responsibilities, activities that can be temporarily abandoned without

consequence, that allow them to respond if and when an emergency occurs. An

established list of projects, educational modules, quality initiatives, unit policies

and guidelines, chart reviews, and clinical practice updates will leave staff

available to respond to emergency situations in times of low census while

improving the clinical practice environment and promoting organizational success.

7. Situations involving neonatal specialty care for fewer than six intermediate-care

patients or four or fewer intensive care patients require a minimum of two RNs with

neonatal expertise and training.

8. Though research about nurse staffing and outcomes in the neonatal population

has increased over the past decade, the issue of how to measure acuity and apply

it to the NICU environment continues to need attention. This population, like

others, is rapidly changing; smaller and less mature infants are becoming more

commonplace. As the population and technology evolve, we must continue to do

the same.

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Drafted by Karen Kopischke, MS NNP RNC; Lori Armstrong, DNP RN NEA-BC;

Annemarie Stopyra Deeley, BSN RN RNC; Kelly Gilhousen, MSN RNC-NIC; and

Jeannette Rogowski. Approved by the National Association of Neonatal Nurses Board of

Directors in September 2021.

may be reproduced without the written consent of the National Association of Neonatal Nurses.

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